Internal Medicine Coding Alert

Question: What is meant by the time spent counseling the patient and coordinating care? Does it include time spent discussing care arrangements with the patients family?

Arkansas Subscriber

Answer: In general, time spent discussing care arrangements with the patients family is considered time spent counseling and coordinating care. The CPT manual states, When counseling and/or coordination of care dominates (more than 50 percent) the physician-patient and/or family encounter (face-to-face time in the office or other outpatient setting or floor/unit time in the hospital or nursing facility), then time may be considered the key or controlling factor to qualify for a particular level of evaluation and management (E/M) service.

Many other sections of the CPT manual also emphasize that time spent counseling the patient can include time spent counseling the patients family. The CPT manual defines counseling as a discussion with a patient and/or a family concerning one or more of the following areas:

diagnostic results, impressions, and/or recommended diagnostic studies;
prognosis;
risk and benefits of management (treatment) options;
instructions for management (treatment) and/or followup;
importance of compliance with chosen management (treatment) options;
risk factor reduction; and
patient and family education.

Discussions with family are also included in face-to-face time and floor/unit time. For office and outpatient E/M services, face-to-face time is only that time that the physician spends face-to-face time with the patient and/or family. When reporting inpatient hospital E/M services, floor/unit time includes Time in which the physician establishes and/or reviews the patients chart, examines the patient, writes notes and communicates with other professionals and the patients family.

Internists may want to record start and stop times for a visit if it is going to be billed based on the element of time spent counseling and coordinating care, according to Catherine A. Brink, CMM, CPC, president of Healthcare Resource Management Inc, a physician practice management consulting firm in Spring Lake, N.J. The internist should write 10:40 a.m. to 11:10 a.m. in the patients medical record and a brief synopsis of what was discussed with the patient, family or other providers, she says.